Healthcare Provider Details

I. General information

NPI: 1154145779
Provider Name (Legal Business Name): MISS JASMINE JENICE KIMBROUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4317 FOREST PARK AVE
SAINT LOUIS MO
63108-2820
US

IV. Provider business mailing address

9669 LYNN TOWN CT
SAINT LOUIS MO
63114-2607
US

V. Phone/Fax

Practice location:
  • Phone: 314-266-8205
  • Fax:
Mailing address:
  • Phone: 314-761-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: